Undergraduate surgery clerkship and the choice of surgery as a career: perspective from a developing country

The Implementation of Simulation-Based Learning for Training Undergraduate Medical Students in Essential Surgical Care Across Sub-Saharan Africa: a Scoping Review

Much surgery in sub-Saharan Africa is provided by non-specialists who lack postgraduate surgical training. These can benefit from simulation-based learning (SBL) for essential surgery. Whilst SBL in high-income contexts, and for training surgical specialists, has been explored, SBL for surgical training during undergraduate medical education needs to be better defined. From 26 studies, we identify gaps in application of simulation to African undergraduate surgical education, including lack of published SBL for most (65%) World Bank-defined essential operations. Most SBL is recent (2017-2021), unsustained, occurs in Eastern Africa (78%), and can be enriched by improving content, participant spread, and collaborations.

¿Se deben confiar actividades profesionales en cirugía mínimamente invasiva al médico general? Una propuesta basada en el aprendizaje experiencial

Introducción. El entrenamiento en cirugía mínimamente invasiva y la definición de las actividades profesionales específicas, socialmente responsables y seguras para el paciente, son un desafío y un deber en la educación médica. Nuestro objetivo es argumentar a favor de esta intervención y describir las especificaciones, alcances y limitaciones de las actividades profesionales confiables a este nivel, así como su lugar en un modelo de aprendizaje experiencial en cirugía mínimamente invasiva para toda la vida. Métodos. Se evalúa el contexto de la actividad quirúrgica asistencial de los médicos generales, con relación a su participación en el equipo quirúrgico y la necesidad de incorporación en su perfil profesional de unas competencias propias de la cirugía mínimamente invasiva, acorde con su nivel y funciones. Mediante una postura académica y reflexiva, se identifican vacíos y oportunidades de avanzar en el tema. Resultados. El perfil profesional de un médico general debe contemplar la cirugía mínimamente invasiva como una competencia dentro de su formación, de manera análoga a las propias de la cirugía tradicional abierta. Para ello, se requiere afrontar coherentemente el cambio de teoría y educación quirúrgica, el cambio en la demanda de servicios quirúrgicos y procedimientos, así como fortalecer el rol activo del médico general en el equipo quirúrgico. Conclusiones. Es necesario modificar el paradigma educativo en cirugía, desde la formación médica en el pregrado. Se plantea un modelo de aprendizaje experiencial de cirugía mínimamente invasiva, y se establecen las competencias fundamentadas en actividades profesionales confiables, necesarias para el perfil profesional de un médico general del siglo XXI.

Development of an Interactive Global Surgery Course for Interdisciplinary Learners

Introduction:

Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care.

Methods:

We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test.

Results:

Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master’s degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving.

Conclusions:

We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide.

Surgeons Underestimate the Importance of Surgical Topics for Non-Surgeons: Results of a National Survey

OBJECTIVE

To determine if surgeons and non-surgeons agree on the importance of surgical topics covered in the surgical clerkship to the daily practice of non-surgeons.

DESIGN

An IRB-approved anonymous survey ranking the relative importance of 35 topics drawn from surgical clerkship curricula asking physicians to rank the relative importance of each topic, using a five-point Likert scale, to the daily practice of non-surgeons.

SETTING

Online anonymous survey.

PARTICIPANTS

Convenience sample of practicing physicians and trainees. The survey was offered to physicians in all specialties via social media and professional connections, responders identified their practice specialty.

RESULTS

295 physicians completed the survey. Two hundred thirty-one (85%) were from non-surgical specialties: emergency medicine (EM, n = 100); primary care (PC, n = 71 - included internal medicine, family medicine, and pediatrics); a variety of others (n = 60).  Surgeons and non-surgeons agreed on the relative importance of the acute abdomen, breast disease, inguinal hernias, inflammatory bowel disease, morbid obesity, sinusitis, thyroid and parathyroid disease, and wound care; surgeons believed colorectal cancer and diverticulitis to be more important. Surgeons rated all other topics as less important to non-surgeons than non-surgeons. EM rated most acute problems more important that PC; both groups ranked most topics higher importance to the practice of a non-surgeon than surgeons (p < 0.05).

CONCLUSIONS

Surgeons consistently underestimate the importance non-surgeons place on surgical topics in their practice.  These results reinforce the perceived importance of a wide exposure to surgery in the surgical clerkship to all medical students - but topics could be focused differently depending on acute or non-acute non-surgical care career plans.

Medical Student And Faculty Perceptions Of Undergraduate Surgical Training In The South African And Swedish Tertiary Institutions: A Cross-Sectional Survey

PURPOSE

To evaluate and compare medical student and faculty perceptions of undergraduate surgical training and compare results between South Africa and Sweden.

PATIENTS AND METHODS

An electronic, online questionnaire was anonymously distributed to medical students and surgical faculty at the University of Cape Town (UCT), South Africa, and the Karolinska Institutet (KI), Sweden. The questionnaire explored the perceptions of medical students and surgical faculty regarding the current undergraduate surgical curriculum, as well as existing clinical and theoretical instructional methods.

RESULTS

A total of 120 students (response rate of 24.4%) and 41 faculty (response rate of 74.5%) responded. Students believed they ought to receive significantly more teaching when compared to surgical faculty (p=0.018). Students and faculty generally agreed that students should expect to study approximately six to 20 hrs per week outside of clinical duty. There was general agreement that "small-group tutorials" was the area students learn the most from, whereas students reported "lectures" least helpful. Registrars were reported as the first person students should consult regarding patient care. Fifty-one (42.5%) medical students believed that faculty viewed students as an inconvenience, and 42 (35.0%) students believed that faculty would rather not have students on the clinical team. The majority of faculty (68.3%) reported significantly more negative views on the current undergraduate surgical curriculum when compared to students (p=0.002). UCT faculty reported giving significantly less feedback to students during their surgical rotation when compared to KI faculty (p=0.043).

CONCLUSION

Significant differences exist between surgical faculty and medical student perceptions regarding undergraduate surgical training in developing and developed countries. In order to increase surgical interest among undergraduate medical students, it is imperative for surgical educators to be aware of these differences and find specific strategies to bridge this gap.

Perception (of) and Willingness to Choose a Neurosurgery Career Among Final-Year Medical Students in Ibadan, Nigeria

BACKGROUND

The deficit in access to neurosurgical care worldwide remains a challenge, particularly in the developing economies such as Nigeria, where the neurosurgeon density is low. The concern that arguably subsists in sub-Saharan Africa is the decline in the number of recruited candidates into surgical specialty training programs, including neurosurgery, despite increasing burden of surgical cases. This study assessed the perception and willingness of medical undergraduates regarding neurosurgery career and determined the factors influencing their choice. This understanding will be critical to advancing ways of motivating them toward a neurosurgery career.

METHODS

A cross-sectional study was conducted among 256 consenting final-year medical students of the College of Medicine, University of Ibadan, Nigeria. Data on the perception (of) and willingness to choose neurosurgery career were obtained. Data were analyzed with descriptive statistics and χ² test at P < 0.05.

RESULTS

The mean age of respondents was 24.9 ± 1.9 years. Within the duration of their clinical trainings, almost all (96.1%) the respondents had 1-2 neurosurgical postings. Although surgery was the most preferred specialty, only 7.8% of the respondents reported a willingness to choose neurosurgery as a career. Proffered reasons for dissatisfaction with neurosurgical postings were unfriendly teaching environment (52.6%) and incessant industrial strikes, coupled with stress among trainers and residents (27.7%). More male than female students were willing to choose neurosurgery career (P = 0.027).

CONCLUSIONS

Our study indicated that the proportion of final-year medical students willing to choose neurosurgery career was low and there was sex disparity in the willingness to pursue a neurosurgical career.

Factors influencing subspecialty choice among medical students: a systematic review and meta-analysis

OBJECTIVE

To characterise the contributing factors that affect medical students' subspecialty choice and to estimate the extent of influence of individual factors on the students' decision-making process.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search of the Cochrane Library, ERIC, Web of Science, CNKI and PubMed databases was conducted for studies published between January 1977 and June 2018. Information concerning study characteristics, influential factors and the extent of their influence (EOI) was extracted independently by two trained investigators. EOI is the percentage level that describes how much each of the factors influenced students' choice of subspecialty. The recruited medical students include students in medical school, internship, residency training and fellowship, who are about to or have just made a specialty choice. The estimates were pooled using a random-effects meta-analysis model due to the between-study heterogeneity.

RESULTS

Data were extracted from 75 studies (882 209 individuals). Overall, the factors influencing medical students' choice of subspecialty training mainly included academic interests (75.29%), competencies (55.15%), controllable lifestyles or flexible work schedules (53.00%), patient service orientation (50.04%), medical teachers or mentors (46.93%), career opportunities (44.00%), workload or working hours (37.99%), income (34.70%), length of training (32.30%), prestige (31.17%), advice from others (28.24%) and student debt (15.33%), with significant between-study heterogeneity (p<0.0001). Subgroup analyses revealed that the EOI of academic interests was higher in developed countries than that in developing countries (79.66% [95% CI 70.73% to 86.39%] vs 60.41% [95% CI 43.44% to 75.19%]; Q=3.51, p=0.02). The EOI value of prestige was lower in developed countries than that in developing countries (23.96% [95% CI 19.20% to 29.47%] vs 47.65% [95% CI 34.41% to 61.24%]; Q=4.71, p=0.01).

CONCLUSIONS

This systematic review and meta-analysis provided a quantitative evaluation of the top 12 influencing factors associated with medical students' choice of subspecialty. Our findings provide the basis for the development of specific, effective strategies to optimise the distribution of physicians among different departments by modifying these influencing factors.

A systematic review of the factors affecting choice of surgery as a career

BACKGROUND

Interest in surgical careers among medical students has declined over the past decade. Multiple explanations have been offered for why top students are deterred or rejected from surgical programs, though no consensus has emerged.

METHODS

We conducted a review of the literature to better characterize what factors affect the pursuit of a surgical career. We searched PubMed and EMBASE and performed additional reference checks. Agency for Healthcare Research and Quality (AHRQ) and Newcastle-Ottawa Education scores were used to evaluate the included data.

RESULTS

Our search identified 122 full-text, primary articles. Analysis of this evidence identified 3 core concepts that impact surgical career decision-making: gender, features of surgical education, and student "fit" in the culture of surgery.

CONCLUSION

Real and perceived gender discrimination has deterred female medical students from entering surgical careers. In addition, limited exposure to surgery during medical school and differences between student and surgeon personality traits and values may deter students from entering surgical careers. We suggest that deliberate and visible effort to include women and early-career medical students in surgical settings may enhance their interest in carreers in surgery.

The Role of the Operating Room in Medical Student Education: Differing Perspectives of Learners and Educators

OBJECTIVE

The surgical clerkship is an integral part of third-year medical student education. The operating room (OR) is a heavily used setting, but it is unclear whether this setting is as effective as possible. To determine the role of the OR and potential improvements, it is necessary to analyze the perspectives of those involved, including surgeons, residents, and medical students.

DESIGN

An electronic survey was distributed to the surgeons, surgical residents, and third-year medical students associated with Rutgers New Jersey Medical School. The questions were a combination of 5-point Likert scale questions and qualitative responses. The questions assessed the role of the OR, the information taught in the OR, the quality of the teaching and environment, and potential improvements.

RESULTS

Attending surgeons and residents generally rated the OR more positively than medical students did. Medical students desired more hands-on participation and a greater focus on learning technical skills. In addition, most medical students rated the feedback and direct instruction in the OR as "poor." Furthermore, the attending surgeons and medical students disagreed about the main roles of the OR as well as the effectiveness of teaching in the OR. The medical students reported experiencing anxiety and intimidation in the OR and suggested several improvements, such as decreasing the length of the surgical clerkship.

CONCLUSIONS

There is significant disagreement between the surgeons and residents and the medical students regarding the roles and effectiveness of learning in the OR. This may help explain the reported medical student dissatisfaction and frustrations with the surgical clerkship.

Portfolios Enhance Clinical Activity in Surgical Clerks

OBJECTIVES

A change in German licensing legislation imposed a portfolio for surgical clerks. We aimed to analyze whether the implementation of the portfolio changed the amount of clinical exposure and activities during surgical clerkships.

DESIGN

The study was conducted with a modified pre-post design at the University Hospital of Tuebingen, Germany. Before and after the implementation of the portfolio on April 1, 2013, final-year students (n = 557) who had just finished their surgical clerkship were interviewed with an online questionnaire. A total of 21 basic surgical skills were evaluated.

RESULTS

Overall, 230 questionnaires were returned and analyzed; 51% were preintervention. Overall clinical activity for the whole study cohort varied for different activities between 98% and 32%. For 16 of 21 parameters, there was more clinical activity in the postintervention (portfolio) group. This difference was statistically significant for the following 7 activities: discharge, analgesia, local infiltration, patient positioning, drain in, blood transfusion, and emergency diagnostics.

CONCLUSION

The implementation of the portfolio did enhance clinical activity for surgical clerks in the study cohort. Nevertheless, overall exposure is still unsatisfactory low for some activities. Additional changes and studies are necessary to further improve surgical education.

Medical Student Quality-of-Life in the Clerkships: A Scale Validation Study

Many aspects of medical school are stressful for students. To empirically assess student reactions to clerkship programs, or to assess efforts to improve such programs, educators must measure the overall well-being of the students reliably and validly. The purpose of the study was to develop and validate a measure designed to achieve these goals. The authors developed a measure of quality of life for medical students by sampling (public domain) items tapping general happiness, fatigue, and anxiety. A quality-of-life scale was developed by factor analyzing responses to the items from students in two different clerkships from 2005 to 2008. Reliability was assessed using Cronbach's alpha. Validity was assessed by factor analysis, convergence with additional theoretically relevant scales, and sensitivity to change over time. The refined nine-item measure is a Likert scaled survey of quality-of-life items comprised of two domains: exhaustion and general happiness. The resulting scale demonstrated good reliability and factorial validity at two time points for each of the two samples. The quality-of-life measure also correlated with measures of depression and the amount of sleep reported during the clerkships. The quality-of-life measure appeared more sensitive to changes over time than did the depression measure. The measure is short and can be easily administered in a survey. The scale appears useful for program evaluation and more generally as an outcome variable in medical educational research.